Acute renal failure: an unacceptable death sentence globally.

A 28-year-old male plantation worker in Bolivia, the father of two young children, was admitted to hospital with a history of vomiting, diarrhoea, and fever, causing severe dehydration. He had a serum creatinine of 396 μmol/L. Despite vigorous intravenous and oral fl uid replacement, his creatinine worsened to 598 μmol/L. Gravity-driven peritoneal dialysis was available at the hospital. The patient was treated and, in a few days, his renal function recovered. He was discharged with a serum creatinine of 123 μmol/L and returned to work in his rural area, his income being the only support for the family. Thanks to peritoneal dialysis, he survived to see his children grow, and maybe even become doctors. In low-income countries, most people who develop acute kidney failure are not as fortunate as this patient. People continue to die as a consequence of this disorder, which is often preventable with simple measures (hydration or treatment of acute infection). Those patients who progress to the stage at which renal replacement therapy would be indicated die because dialysis is simply not available. This fact is disturbing because there is an excellent chance of survival with full recovery when the kidney is given enough time to recover and life is sustained by dialysis. We believe that access to acute kidney failure treatment should be considered to be part of the right to the highest attainable standard of care. The relevance of acute kidney failure as a major problem for public health has been recently emphasised in guidance issued by the UK’s National Institute for Health and Care Excellence (NICE). NICE estimate that acute kidney failure costs the UK National Health Service £434–620 million every year—more than do breast, lung, and skin cancer combined. Moreover, according to NICE, adequate care of acute kidney failure could avoid 42 000 deaths every year. The global burden of acute kidney failure is calculated to be 13·3 million cases per year, 11·3 million of which are in low-income countries. These numbers are based on the assumption that acute kidney failure has a similar incidence in high-income and low-income countries. However, it is diffi cult to defi ne the incidence of acute kidney failure in lowincome countries, where more than half the world’s population lives. No nationwide disease registries are available, and data are usually derived from singlecentre experience. A recent study by Imani and colleagues showed that among more than 2000 hospital admissions for gastroenteritis, malaria, and pneumonia in Kampala, Uganda, acute kidney failure was present in 13·5% of patients. In patients with gastroenteritis, the prevalence of acute kidney failure was 28·6%. The overall mortality rate was 25%, whereas mortality was 9·9% in similar patients who did not develop acute kidney failure. In low-income countries, acute kidney failure commonly occurs in the community and is generally a disease of the young. The high prevalence of acute kidney failure in young people, who are at their productive peak, has important socioeconomic consequences because their sickness imposes severe poverty upon families through deprivation of income. What is especially tragic is that, in low-income countries, patients frequently develop acute kidney failure as a complication of a single, potentially preventable, treatable, and reversible disease. Access to renal replacement therapy is limited to fewer than 5% of patients who need it, especially in sub-Saharan Africa. The common understanding is that dialysis treatment is too costly and too complex to be delivered in low-resource settings. Although true for haemodialysis or other extracorporeal techniques, this